Hospital employees still reluctant to get flu shots
Only 27% of HCWs report getting shots
As flu season approaches, employee health services at hospitals across the United States face the perennial challenge of convincing their employees to get vaccinated against the onslaught of the disease. Yet compliance rates at many hospitals remain dismally low — a situation that baffles infection control experts, who each year stress the fact that hospital employees and patients are prime vectors for spreading influenza.
Whether health care workers don’t get vaccinated because they aren’t aware of their risk for contracting influenza or whether they avoid vaccinations for other reasons, the results are the same. Nationally, only 27% of health care workers report having gotten a flu shot the previous year, according to Raymond Strikas, MD, medical epidemiologist with the National Immunization Program at the Centers for Disease Control and Prevention.
"It seems difficult to get more than a 30% compliance rate [among hospital employees]," he says, even when hospitals make special efforts to promote the need for and benefits of vaccination. Unpublished reports suggest that under the best of circumstances, flu vaccination rates among health care workers rarely climb above 50%.
Contracting flu should not be a concern
Why is there such reluctance among hospital employees to get a flu shot? Many are worried that the vaccine, which contains live, attenuated influenza virus, will generate a case of the flu, explains Strikas. The concern is legitimate among older people and those who are immunocompromised, but healthy adults have little to worry about. At least one large, double-blind, placebo-controlled, randomized study confirmed that flu-like side effects caused by the vaccine are rare. Influenza vaccination of healthy working adults was not associated with higher rates of systemic symptoms when compared with placebo injection.1
Many health care workers just don’t consider the flu a serious issue or believe that youth and relative health will protect them, says Strikas. Though flu poses little more threat than lost work time, disruption of daily life, and discomfort for most adults, younger people are no less likely to contract the disease than anybody else is. A few workers may just want to avoid a needlestick.
"It’s very important to try and increase use of the vaccine among health care workers, because they can easily transmit the flu to people at high risk for complications, such as older adults," says Lynnette Brammer, MPH, an epidemiologist with the Influenza Branch of the CDC. "We definitely see this as a very important and high priority."
The CDC recommends that physicians and health care institutions begin flu vaccinations in September and schedule major vaccine campaigns for October through mid-November, though vaccinations up to and after influenza activity begins are also endorsed.
"You want to vaccinate early enough for people to develop antibodies, but not so early that antibody levels decline to unprotective levels when the flu arrives," Brammer explains.
To increase compliance among health care workers, the CDC suggests that health care facilities develop policies and programs to persuade employees that flu vaccinations have a direct impact on their own health and on their jobs, and to make vaccinations accessible.
"Reminders and education are necessary, but not sufficient alone," says Strikas. "A multifactorial approach seems to make a difference in the more successful programs." Some health care professionals have proposed that the Joint Commission on Accreditation of Health Care Organizations institute guidance for flu vaccinations of hospital employees, but no such action has been taken.
Recently, the CDC published recommendations to help improve vaccination rates in children, adolescents, and adults.2 The report states that "A starting point for addressing vaccine-preventable disease problems in communities and health care systems is to assess activities currently being performed, current levels of vaccination coverage, and information regarding vaccine-preventable disease rates. In addition to assessing overall progress towards vaccination goals, health planners should also consider whether special attention is warranted for population groups at high risk."
Last year, one children’s hospital in New Orleans increased vaccination rates among employees by more than 50% by using a combination of education, reminder letters mailed to employees, notices posted in common areas, and vaccination carts wheeled to all nursing units and other locations in the facility.3
Self-interest motivated employee vaccinations
A survey mailed to employees who had been vaccinated the previous year found that nearly 80% of vaccinated workers received the injection because they were concerned for their personal health, not for the well-being of hospitalized patients. That finding guided the hospital’s future vaccination promotion efforts.
The main reason given for not being vaccinated was concern about being infected by the vaccine itself, even though flu-like symptoms were reported at similar rates among vaccinated and non-vaccinated workers and symptoms tended to be much milder among vaccinated individuals. Administrators also found that pregnant women avoided flu shots because their physicians told them to, though many experts believe such advice is wrong.
Even vigorous, well-coordinated efforts to boost vaccine compliance may fall short. At Emory Uni versity Hospital in Atlanta, annual compliance rates among employees hover at 30% to 35%. The hospital’s Occupational Health Service set out to determine why so many employees didn’t get vaccinated and to increase compliance.
"For a long time, we’ve taken the vaccine around the hospital and clinic on rolling carts. We visit every nursing unit at least twice during each flu season and make ourselves very visible in high-traffic areas, such as the cafeteria at meal times," says Jeanne Culver, RN, COHN-S, clinical manager of Emory Hospital’s Occupational Health Services. Her department also distributes brightly colored flyers at least twice yearly to all hospital departments — once prior to flu season and again after the season has begun.
"The vaccinations are available until we run out, which is usually at the end of December, but there’s no time limit. We’ll give it to people who are late deciding that they want it. Employees can also get vaccinated at Employee Health Services on a drop-in basis, but we still have many people who remain unvaccinated," says Culver.
Culver even offered gift certificates from major retailers for units that logged the highest compliance rates. Parties were thrown for the winners, as well.
"We made it a competition and found that it had absolutely no impact on individual decisions. People either ignored it, didn’t read our literature, or dismissed it. We found that some employees were surprised when our clinical staff reminded them they were eligible for gift certificates," Culver says.
Inexplicably, compliance rates dropped by 3% to 4% from the previous year, during which no monetary incentives were offered.
The reasons most often articulated by workers for not getting the vaccine included the fear of side effects such as getting the flu, a sore arm, and muscle aches. Many believe they aren’t susceptible to the virus, adds Culver.
This year, Culver will use a survey to determine why compliance rates are so low. She also intends to publicize the incentives even more aggressively. Once again, rolling carts will prowl the hospital’s halls and visit all units. In the past, use of the roaming carts meant that a staff nurse had to be removed from patient-care duty. This year, Culver has arranged for students from the school of nursing to take on the job under the supervision of a preceptor.
"The nursing students will get lots of experience giving intramuscular injections, and they’ll be supervised by a nurse. The idea has been well-received by the school, and the initial anxiety of the staff was alleviated when they learned that an occupational health nurse would be present."
The pending release of an intranasal flu vaccine may raise national compliance rates. Researchers found that subjects who received the new vaccine, which contains live, attenuated influ enza virus, were "as likely to experience one or more febrile illnesses as placebo recipients during peak outbreak periods. However, the vaccine significantly reduced the numbers of severe febrile illnesses and febrile upper respiratory tract illnesses."4
The vaccination also reduced the duration of all flu-related symptoms, reduced the number of lost work days, and resulted in fewer visits to health care providers.
Reference
1. Nichol KL, Margolis KL, Lin A, et al. Side effects associated with influenza vaccination in healthy working adults. Arch Int Med 1996; 156:1,546-1,550.
2. Centers for Disease Control and Prevention. Vaccine-preventable diseases: Improving vaccination coverage in children, adolescents, and adults. A report on recommendations for the Task Force on Community Preventive Services. MMWR 1999; 48(RR-8):1-15.
3. Begue RE, Gee SQ. Improving influenza immunization among health care workers. Infect Control Hosp Epidemiol 1998; 19:518-520.
4. Nichol KL, Mendelman PM, Mallon KP, et al. Effectiveness of live, attenuated intranasal influenza virus vaccine in healthy, working adults. JAMA 1999; 282:137-144.
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